Utilisation and costs of community mental health services. PRiSM Psychosis Study. 5

Descriptive outcomes for a cohort of high-frequency psychiatric service users in the Western Cape, South Africa after 10 years

Background: Assertive community treatment (ACT) is an intervention implemented to manage the effects of deinstitutionalisation. South African studies have reported decreased admissions at 12 and 36 months when a modified ACT intervention is compared with standard care. However, costs associated with the intervention have raised the question of its feasibility in developing countries.Aim: This study aimed to describe the long-term demographic and clinical outcomes of a group of psychiatric high-frequency users (HFUs) included in the first South African ACT study.Setting: Stikland Psychiatric Hospital, Cape Town, South Africa.Methods: Data from 55 HFUs participating in the first South African ACT trial, including both the intervention and control groups, were retrospectively reviewed 10 years after the patients’ inclusion.Results: Of the 55 HFUs initially included, nine remained in the formal ACT programme whilst 16 received standard care over the full 10 years. Five patients died and two were admitted to long-term wards. The mean number of admissions was 3.73 and the mean number of admission days was 261.11 over the 10 years. Twelve patients were never re-admitted; of these, nine came from the original study intervention group.Conclusions: This was the first study looking at the long-term outcomes of a group of psychiatric HFUs in an under-resourced setting receiving either a modified ACT intervention or standard outpatient care. Reflecting broadly on the group, there were a larger number of patients in the original ACT group who had no re-admissions and a comparatively higher utilisation of available services during the 10-year follow-up period.

Cost of a community mental health service: a retrospective study on a psychosocial care center for alcohol and drug users in São Paulo

BACKGROUND

Psychosocial care centers for alcohol and drug users (CAPS-ad) are reference services for treatment of drug users within the Brazilian National Health System. Knowledge of their total costs within the evidence-based decision-making process for public-resource allocation is essential. The aims here were to estimate the total costs of a CAPS-ad and the costs of packages of care (according to intensity of care); to ascertain the ratio between total CAPS-ad costs and the federal funding allocated; and to describe the methods for estimating unit costs for each CAPS-ad cost component.

DESIGN AND SETTING

Retrospective study conducted in a public community mental health service.

METHODS

This was a retrospective cost description study on a CAPS-ad located in a city in the state of São Paulo, using a public healthcare provider perspective and a top-down approach, conducted over a 180-day period from March 1 to August 30, 2015.

RESULTS

The total mean monthly costs of the CAPS-ad were BRL 64,017.54. Healthcare staff accounted for 56.5% of total costs. The mean costs per capita and per month for intensive and non-intensive care packages were, respectively, BRL 668.34 and BRL 37.12.

CONCLUSIONS

The federal budget allocation covered 62.1% of the CAPS-ad costs and the remaining 37.9% end up funded by the municipal government. The cost of the intensive package of care was 18 times greater than the non-intensive package. Developing criteria for using services and different packages of care based on patients' needs, and optimizing human resources according to specific actions, may improve people's mental health and avoid wasted resources.

Supply factors as determinants of treatment costs: clinicians' assessments of a given set of referrals to community mental health centers in Norway

BACKGROUND

Previous works that uses patterns of prior spending to predict future mental health care expenses (utilization models) are mainly concerned with demand (need) variables. In this paper, we introduce supply variables, both individual rater variables and center variables. The aim is to assess these variables' explanatory power, and to investigate whether not accounting for such variables could create biased estimates for the effects of need variables.

METHODS

We employed an observational study design where the same set of referrals was assessed by a sample of clinicians, thus creating data with a panel structure being particularly relevant for analyzing supply factors. The referrals were obtained from Norwegian Community Mental Health Centers (outpatient services), and the clinicians assessed the referrals with respect to recommended treatment costs and health status.

RESULTS

Supply variables accounted for more than 10% of the total variation and about one third of the explained variation. Two groups of supply variables, individual rater variables and center variables (institutions) were equally important.

CONCLUSIONS

Our results confirm that supply factors are important but ignoring such variables, when analyzing demand variables, do not generally seem to produce biased (confounded) coefficients.

Costs of the police service and mental healthcare pathways experienced by individuals with enduring mental health needs

BACKGROUND

Substantial policy, communication and operational gaps exist between mental health services and the police for individuals with enduring mental health needs.

AIMS

To map and cost pathways through mental health and police services, and to model the cost impact of implementing key policy recommendations.

METHOD

Within a case-linkage study, we estimated 1-year individual-level healthcare and policing costs. Using decision modelling, we then estimated the potential impact on costs of three recommended service enhancements: street triage, Mental Health Act assessments for all Section 136 detainees and outreach custody link workers.

RESULTS

Under current care, average 1-year mental health and police costs were £10 812 and £4552 per individual respectively (n = 55). The cost per police incident was £522. Models suggested that each service enhancement would alter per incident costs by between -8% and +6%.

CONCLUSIONS

Recommended enhancements to care pathways only marginally increase individual-level costs.

Intensive case management for severe mental illness

BACKGROUND

Intensive Case Management (ICM) is a community-based package of care aiming to provide long-term care for severely mentally ill people who do not require immediate admission. Intensive Case Management evolved from two original community models of care, Assertive Community Treatment (ACT) and Case Management (CM), where ICM emphasises the importance of small caseload (fewer than 20) and high-intensity input.

OBJECTIVES

To assess the effects of ICM as a means of caring for severely mentally ill people in the community in comparison with non-ICM (caseload greater than 20) and with standard community care. We did not distinguish between models of ICM. In addition, to assess whether the effect of ICM on hospitalisation (mean number of days per month in hospital) is influenced by the intervention's fidelity to the ACT model and by the rate of hospital use in the setting where the trial was conducted (baseline level of hospital use).

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's Trials Register (last update search 10 April 2015).

SELECTION CRITERIA

All relevant randomised clinical trials focusing on people with severe mental illness, aged 18 to 65 years and treated in the community care setting, where ICM is compared to non-ICM or standard care.

DATA COLLECTION AND ANALYSIS

At least two review authors independently selected trials, assessed quality, and extracted data. For binary outcomes, we calculated risk ratio (RR) and its 95% confidence interval (CI), on an intention-to-treat basis. For continuous data, we estimated mean difference (MD) between groups and its 95% CI. We employed a random-effects model for analyses.We performed a random-effects meta-regression analysis to examine the association of the intervention's fidelity to the ACT model and the rate of hospital use in the setting where the trial was conducted with the treatment effect. We assessed overall quality for clinically important outcomes using the GRADE approach and investigated possible risk of bias within included trials.

MAIN RESULTS

The 2016 update included two more studies (n = 196) and more publications with additional data for four already included studies. The updated review therefore includes 7524 participants from 40 randomised controlled trials (RCTs). We found data relevant to two comparisons: ICM versus standard care, and ICM versus non-ICM. The majority of studies had a high risk of selective reporting. No studies provided data for relapse or important improvement in mental state.1. ICM versus standard careWhen ICM was compared with standard care for the outcome service use, ICM slightly reduced the number of days in hospital per month (n = 3595, 24 RCTs, MD -0.86, 95% CI -1.37 to -0.34,low-quality evidence). Similarly, for the outcome global state, ICM reduced the number of people leaving the trial early (n = 1798, 13 RCTs, RR 0.68, 95% CI 0.58 to 0.79, low-quality evidence). For the outcome adverse events, the evidence showed that ICM may make little or no difference in reducing death by suicide (n = 1456, 9 RCTs, RR 0.68, 95% CI 0.31 to 1.51, low-quality evidence). In addition, for the outcome social functioning, there was uncertainty about the effect of ICM on unemployment due to very low-quality evidence (n = 1129, 4 RCTs, RR 0.70, 95% CI 0.49 to 1.0, very low-quality evidence).2. ICM versus non-ICMWhen ICM was compared with non-ICM for the outcome service use, there was moderate-quality evidence that ICM probably makes little or no difference in the average number of days in hospital per month (n = 2220, 21 RCTs, MD -0.08, 95% CI -0.37 to 0.21, moderate-quality evidence) or in the average number of admissions (n = 678, 1 RCT, MD -0.18, 95% CI -0.41 to 0.05, moderate-quality evidence) compared to non-ICM. Similarly, the results showed that ICM may reduce the number of participants leaving the intervention early (n = 1970, 7 RCTs, RR 0.70, 95% CI 0.52 to 0.95,low-quality evidence) and that ICM may make little or no difference in reducing death by suicide (n = 1152, 3 RCTs, RR 0.88, 95% CI 0.27 to 2.84, low-quality evidence). Finally, for the outcome social functioning, there was uncertainty about the effect of ICM on unemployment as compared to non-ICM (n = 73, 1 RCT, RR 1.46, 95% CI 0.45 to 4.74, very low-quality evidence).3. Fidelity to ACTWithin the meta-regression we found that i.) the more ICM is adherent to the ACT model, the better it is at decreasing time in hospital ('organisation fidelity' variable coefficient -0.36, 95% CI -0.66 to -0.07); and ii.) the higher the baseline hospital use in the population, the better ICM is at decreasing time in hospital ('baseline hospital use' variable coefficient -0.20, 95% CI -0.32 to -0.10). Combining both these variables within the model, 'organisation fidelity' is no longer significant, but the 'baseline hospital use' result still significantly influences time in hospital (regression coefficient -0.18, 95% CI -0.29 to -0.07, P = 0.0027).

AUTHORS' CONCLUSIONS

Based on very low- to moderate-quality evidence, ICM is effective in ameliorating many outcomes relevant to people with severe mental illness. Compared to standard care, ICM may reduce hospitalisation and increase retention in care. It also globally improved social functioning, although ICM's effect on mental state and quality of life remains unclear. Intensive Case Management is at least valuable to people with severe mental illnesses in the subgroup of those with a high level of hospitalisation (about four days per month in past two years). Intensive Case Management models with high fidelity to the original team organisation of ACT model were more effective at reducing time in hospital.However, it is unclear what overall gain ICM provides on top of a less formal non-ICM approach.We do not think that more trials comparing current ICM with standard care or non-ICM are justified, however we currently know of no review comparing non-ICM with standard care, and this should be undertaken.

Engaging People with Enduring Psychotic Conditions in Primary Mental Health Care and Occupational Therapy

For people who have enduring psychotic conditions, interventions need to improve social functioning as well as reducing clinical problems. There is also a need to engage and keep in touch with general practitioner (GP) patients who have fallen out of contact with specialist psychiatric care.

A new model of service was designed to engage this patient group: an expanded primary care team in an inner-city area. The team extended the GP role, provided occupational therapy and care management and used liaison psychiatry. A case study design with mixed methods was used to investigate the new service. This article reports the quantitative investigation of engagement, clinical and social outcomes and cost consequences.

The results showed that, at the start of the study, 37 people with psychotic conditions were in the sole care of their GPs; of these, 34 (92%) engaged with the new service. The sample of 28 receiving 12 months' interventions started with low levels of social functioning, which required intervention. Following interventions, they showed significant improvements in social functioning, clinical symptoms and Health of the Nation Outcome Scales (HoNOS). The costs were favourable when compared with similar services. The study suggests that expanded primary care, with occupational therapy and care management, can be a feasible service to improve people's engagement and functioning.

A Review of Economic Evaluations of Community Mental Health Care

The authors review the methodology and findings of economic evaluations of 42 community mental health care programs reported in the English-language literature between 1979 and 2003. There were three substantial methodological problems in the literature: costs were often not completely specified, the quality of econometric analysis was often low, and most evaluations failed to integrate cost and health outcome information. Well-conducted research shows that care in the community dominates hospital in-patient care, achieving better outcomes at lower or equal cost. It is less clear what types of community programs are most cost-effective. Future research should focus on identifying which types of community care are most cost effective and at what level of intensity they are most effective.

The association between continuity of care and readmission to hospital in patients with severe psychosis

PURPOSE

Providing good continuity of care to patients is considered a vital component of community mental health services, but there is limited evidence that it is associated with good outcomes. We measured service use and a multidimensional concept of continuity of care in 323 patients who were to be discharged from hospital following compulsory treatment for psychosis to investigate the association between continuity and rehospitalisation.

METHODS

We conducted a 36-month prospective cohort study of the patients recruited to the Oxford Community Treatment Order Trial (OCTET). We collected data from medical records on eight previously operationalized measures of continuity. We conducted regression analyses to determine the association between these measures and readmission to hospital, time to readmission, and the number of days spent in hospital.

RESULTS

Almost two thirds (n = 206, 63.8%) of patients were readmitted. Patients were seen frequently, with a mean of 2.9 (SD = 2.47) contacts a month throughout the follow-up. Less frequent contact was significantly associated with lower odds of rehospitalisation and fewer days in hospital. More changes in the patient's care coordinator were associated with more time in hospital. Patients who had a higher proportion of clinical correspondence copied to them spent fewer days in hospital.

CONCLUSION

Patients with severe and relapsing psychotic illness are seen frequently and consistently in community mental health services. Higher levels of patient contact could be a response to the severity of illness rather than a marker of quality of care. Using a simple linear interpretation of contact frequency as a measure of continuity of care in this patient group may be of limited value in modern services.

Developing models of how cognitive improvements change functioning: mediation, moderation and moderated mediation

BACKGROUND

Cognitive remediation (CRT) affects functioning but the extent and type of cognitive improvements necessary are unknown.

AIM

To develop and test models of how cognitive improvement transfers to work behaviour using the data from a current service.

METHOD

Participants (N49) with a support worker and a paid or voluntary job were offered CRT in a Phase 2 single group design with three assessments: baseline, post therapy and follow-up. Working memory, cognitive flexibility, planning and work outcomes were assessed.

RESULTS

Three models were tested (mediation - cognitive improvements drive functioning improvement; moderation - post treatment cognitive level affects the impact of CRT on functioning; moderated mediation - cognition drives functioning improvements only after a certain level is achieved). There was evidence of mediation (planning improvement associated with improved work quality). There was no evidence that cognitive flexibility (total Wisconsin Card Sorting Test errors) and working memory (Wechsler Adult Intelligence Scale III digit span) mediated work functioning despite significant effects. There was some evidence of moderated mediation for planning improvement if participants had poorer memory and/or made fewer WCST errors. The total CRT effect on work quality was d=0.55, but the indirect (planning-mediated CRT effect) was d=0.082

CONCLUSION

Planning improvements led to better work quality but only accounted for a small proportion of the total effect on work outcome. Other specific and non-specific effects of CRT and the work programme are likely to account for some of the remaining effect. This is the first time complex models have been tested and future Phase 3 studies need to further test mediation and moderated mediation models.

Programas de continuidad de cuidados: éxitos, fracasos y retos futuros

Los programas de continuidad de cuidados surgen a finales de los años 70 en EEUU, en respuesta a los problemas detectados durante del proceso de desintitucionalización de los hospitales psiquiátricos. Desde entonces, se han extendido por todo el mundo, con variaciones y peculiaridades según las regiones, convirtiéndose en piedra angular de la atención a las personas con enfermedad mental grave y persistente. En este artículo se revisa el origen de estos programas, su desarrollo a lo largo de más de treinta años, la filosofía que los ha guiado en su devenir, así como los éxitos y fracasos en su desarrollo.

Intensive case management for severe mental illness

BACKGROUND

Intensive Case Management (ICM) is a community based package of care, aiming to provide long term care for severely mentally ill people who do not require immediate admission. ICM evolved from two original community models of care, Assertive Community Treatment (ACT) and Case Management (CM), where ICM emphasises the importance of small caseload (less than 20) and high intensity input.

OBJECTIVES

To assess the effects of Intensive Case Management (caseload <20) in comparison with non-Intensive Case Management (caseload > 20) and with standard community care in people with severe mental illness. To evaluate whether the effect of ICM on hospitalisation depends on its fidelity to the ACT model and on the setting.

SEARCH STRATEGY

For the current update of this review we searched the Cochrane Schizophrenia Group Trials Register (February 2009), which is compiled by systematic searches of major databases, hand searches and conference proceedings.

SELECTION CRITERIA

All relevant randomised clinical trials focusing on people with severe mental illness, aged 18 to 65 years and treated in the community-care setting, where Intensive Case Management, non-Intensive Case Management or standard care were compared. Outcomes such as service use, adverse effects, global state, social functioning, mental state, behaviour, quality of life, satisfaction and costs were sought.

DATA COLLECTION AND ANALYSIS

We extracted data independently. For binary outcomes we calculated relative risk (RR) and its 95% confidence interval (CI), on an intention-to-treat basis. For continuous data we estimated mean difference (MD) between groups and its 95% confidence interval (CI). We employed a random-effects model for analyses.We performed a random-effects meta-regression analysis to examine the association of the intervention's fidelity to the ACT model and the rate of hospital use in the setting where the trial was conducted with the treatment effect.

MAIN RESULTS

We included 38 trials (7328 participants) in this review. The trials provided data for two comparisons: 1. ICM versus standard care, 2. ICM versus non-ICM.1. ICM versus standard care Twenty-four trials provided data on length of hospitalisation, and results favoured Intensive Case Management (n=3595, 24 RCTs, MD -0.86 CI -1.37 to -0.34). There was a high level of heterogeneity, but this significance still remained when the outlier studies were excluded from the analysis (n=3143, 20 RCTs, MD -0.62 CI -1.00 to -0.23). Nine studies found participants in the ICM group were less likely to be lost to psychiatric services (n=1633, 9 RCTs, RR 0.43 CI 0.30 to 0.61, I²=49%, p=0.05).One global state scale did show an Improvement in global state for those receiving ICM, the GAF scale (n=818, 5 RCTs, MD 3.41 CI 1.66 to 5.16). Results for mental state as measured through various rating scales, however, were equivocal, with no compelling evidence that ICM was really any better than standard care in improving mental state. No differences in mortality between ICM and standard care groups occurred, either due to 'all causes' (n=1456, 9 RCTs, RR 0.84 CI 0.48 to 1.47) or to 'suicide' (n=1456, 9 RCTs, RR 0.68 CI 0.31 to 1.51).Social functioning results varied, no differences were found in terms of contact with the legal system and with employment status, whereas significant improvement in accommodation status was found, as was the incidence of not living independently, which was lower in the ICM group (n=1185, 4 RCTs, RR 0.65 CI 0.49 to 0.88).Quality of life data found no significant difference between groups, but data were weak. CSQ scores showed a greater participant satisfaction in the ICM group (n=423, 2 RCTs, MD 3.23 CI 2.31 to 4.14).2. ICM versus non-ICM The included studies failed to show a significant advantage of ICM in reducing the average length of hospitalisation (n=2220, 21 RCTs, MD -0.08 CI -0.37 to 0.21). They did find ICM to be more advantageous than non-ICM in reducing rate of lost to follow-up (n=2195, 9 RCTs, RR 0.72 CI 0.52 to 0.99), although data showed a substantial level of heterogeneity (I²=59%, p=0.01). Overall, no significant differences were found in the effects of ICM compared to non-ICM for broad outcomes such as service use, mortality, social functioning, mental state, behaviour, quality of life, satisfaction and costs.3. Fidelity to ACT Within the meta-regression we found that i. the more ICM is adherent to the ACT model, the better it is at decreasing time in hospital ('organisation fidelity' variable coefficient -0.36 CI -0.66 to -0.07); and ii. the higher the baseline hospital use in the population, the better ICM is at decreasing time in hospital ('baseline hospital use' variable coefficient -0.20 CI -0.32 to -0.10). Combining both these variables within the model, 'organisation fidelity' is no longer significant, but 'baseline hospital use' result is still significantly influencing time in hospital (regression coefficient -0.18 CI -0.29 to -0.07, p=0.0027).

AUTHORS' CONCLUSIONS

ICM was found effective in ameliorating many outcomes relevant to people with severe mental illnesses. Compared to standard care ICM was shown to reduce hospitalisation and increase retention in care. It also globally improved social functioning, although ICM's effect on mental state and quality of life remains unclear. ICM is of value at least to people with severe mental illnesses who are in the sub-group of those with a high level of hospitalisation (about 4 days/month in past 2 years) and the intervention should be performed close to the original model.It is not clear, however, what gain ICM provides on top of a less formal non-ICM approach.We do not think that more trials comparing current ICM with standard care or non-ICM are justified, but currently we know of no review comparing non-ICM with standard care and this should be undertaken.

The rise and fall of assertive community treatment?

Assertive community treatment is one of the most researched and clinically replicated of all community mental health teams. It is clearly defined with established scales to measure its model fidelity. In the last decade its earlier claims to substantially reduce hospitalization have not been replicated in research studies. This inconsistency has generated considerable controversy. A careful systematic review and meta-regression analysis was conducted of 64 trials including 7,819 patients. The review included measures of model fidelity and hospitalization outcomes. Variation in reduced hospitalization was found to be mainly due to variation in control service practice but model fidelity to team organization principles was also associated with reduced hospitalization. Low caseloads and specified ACT staffing, however, had no effect at all on outcome. 'Ordinary CMHTs' share most of the organizational aspects of ACT and appear to deliver equal outcomes with much reduced resources. The value of investing in high fidelity ACT teams must, therefore, be in doubt.

Schizophrenia patients with cognitive deficits: factors associated with costs

Cognitive deficits in people with schizophrenia are associated with poor functioning and lower quality of life. Because few studies have examined their relationship with service use or costs, it is unclear whether effective cognitive remediation interventions have potential for economic impacts. This study examined associations between cognition and costs among people with schizophrenia. Baseline data collected between 1999 and 2002 from a randomized controlled trial of cognitive remediation therapy were analyzed. A total of 85 participants were recruited from a London mental health trust if they had a diagnosis of schizophrenia, evidence of cognitive/social functioning difficulties, and at least 1 year since first contact with psychiatric services. Cognition levels, social functioning, symptoms, sociodemographic characteristics, and retrospective use of health/social care and other resources were measured. Average public sector costs were estimated to be 15 078 pounds(23 824 dollars) for a 6-month period. Associations between health/social care costs and type and severity of cognition were examined using structural equation models. No significant relationships were found between cognition and costs in a model based on 3 independent constituent components of cognition (cognitive shifting, verbal working memory, and response inhibition), although a model with covarying cognition components fitted the observed data well. A model with cognition as a single construct both fitted well and showed a significant relationship. In people with schizophrenia and severe cognitive impairment, improvements in either overall cognition or specific cognitive components may impact on costs. Further investigation in larger samples is needed to confirm this finding and to explore its generalizability to those with less severe deficits.

Ethnic differences in mental health service use among patients with psychotic disorders

BACKGROUND

There are concerns that ethnic minority patients are over-represented in inpatient mental health settings, but under-utilise community services. This study aims to compare the use of community mental health services between African-Caribbean and White patients with psychosis, before and after the introduction of new community services, and to investigate their impact on inpatient treatment.

METHODS

The sample was drawn from epidemiologically representative patients with psychotic disorders living in two catchment areas in South London, one of which was developing intensive community treatments. Service utilisation was measured at baseline and at 2-year follow-up using the Client Service Receipt Interview (CSRI). The mean number of contacts with specific services was compared between the two groups over time.

RESULTS

A total of 92 White and 48 African-Caribbean patients were compared. The latter were more likely to be younger (P = 0.004), have shorter illness duration (P < 0.001), and had more detentions under the Mental Health Act (P = 0.003). No significant differences were seen in use of community services over time. However, intensive treatment led to a significant reduction in hospital days for African Caribbean patients compared to White patients in the intensive sector and all patients in the standard sector.

CONCLUSIONS

Intensive community treatments reduced inpatient days in African Caribbean patients. Further effort is needed to improve the cultural sensitivity of community mental health services.

Cost-of-illness analysis

Cost-of-illness (COI) was the first economic evaluation technique used in the health field. The principal aim was to measure the economic burden of illness to society. Its usefulness as a decision-making tool has however been questioned since its inception. The main criticism came from welfare economists who rejected COIs because they were not grounded in welfare economics theory. Other attacks related to the use of the human capital approach (HCA) to evaluate morbidity and mortality costs since it was said that the HCA had nothing to do with the value people attach to their lives. Finally, objections were made that COI could not be of any help to decision makers and that other forms of economic evaluation (e.g. cost-effectiveness, cost-benefit analysis) would be much more useful to those taking decisions and ranking priorities. Conversely, it is here suggested that COI can be a good economic tool to inform decision makers if it is considered from another perspective. COI is a descriptive study that can provide information to support the political process as well as the management functions at different levels of the healthcare organisations. To do that, the design of the study must be innovative, capable of measuring the true cost to society; to estimate the main cost components and their incidence over total costs; to envisage the different subjects who bear the costs; to identify the actual clinical management of illness; and to explain cost variability. In order to reach these goals, COI need to be designed as observational bottom-up studies.

[Care requirements for severe mental disorders. Scientific evidence for integration of clinical psychiatry and community psychiatry]

In Germany it is not clear which forms of community mental health care should be encouraged to meet the needs particularly of the severely mentally ill. We performed a literature review of systematic meta-analyses and controlled trials and show that a set of well-evaluated and effective psychiatric care systems is available, of which only a few are being implemented in Germany. It becomes obvious that in Germany organizational requirements for an integration of psychiatric services are not being adequately met, particularly in the case of schizophrenia. Team-based assertive community treatment, crisis intervention teams, community mental health teams, and modern job rehabilitation programs, which have been established primarily in English-speaking countries, could not be effectively adapted for German psychiatric care. At the same time many psychiatric care models have been poorly evaluated. Given the available scientific evidence we comment on future requisites and further developments in German psychiatry to meet the growing need of care for people with severe mental illnesses.

The Maudsley long-term follow-up of child and adolescent depression. Predicting costs in adulthood

BACKGROUND

Little is known about the long-term economic impact of childhood depression. The aim of this study is to identify and examine the links between the characteristics of children with depression and the costs of services used in adulthood.

METHODS

Subjects (N=149) who had attended psychiatric services in South London for depression were followed up on average 20.7 years later. Sociodemographic and illness characteristics were recorded in childhood and service use in adulthood was measured. Costs were calculated and multiple regression models were developed to explain variations in cost, with a comparison between ordinary least squares estimation and a generalised linear model.

RESULTS

Service use and cost data were available on 140 subjects. The mean annual cost was 890 pounds Sterling (range 0 pounds Sterling-7532 pounds Sterling). Predictors of cost variations in both models were age at initial referral, level of childhood anxiety, and the presence of comorbid conduct disorder. In the ordinary least squares model, a family history of psychiatric illness was inversely related to cost, whilst in the generalised linear model there was an inverse link between peer/sibling relationship problems and costs. The models could explain 24 % and 20% of cost variation, respectively.

CONCLUSIONS

It is possible to explain a reasonable amount of variation in adult service costs from factors describing the characteristics of children at the time of receiving care.

Assertive community treatment of the mentally ill: service model and effectiveness

OBJECTIVE

To provide a description of the service delivery model of an assertive community treatment (ACT) team in the management of a group of severely mentally ill patients and examine the effectiveness of this team in reducing readmissions to a psychiatric inpatient service.

METHOD

A clinical case audit was performed on a single day in September 2001. Admission episodes and duration were collected for patients registered with the team in the 12 month period prior to ACT and for a period of 12 months ending on the day of the audit. Forty-three patients were registered with the team at the time of data collection. The majority (79%) were diagnosed with schizophrenia and there were high rates of comorbidity (76%) and disability (mean Global Assessment of Functioning score 45.9). The main outcome measures were the number of readmissions and readmission days before and after the institution of ACT.

RESULTS

The mean number of readmission days reduced from 70.9 to 10.2 (p<0.05) following the institution of ACT.

CONCLUSION

Assertive community treatment conducted in a naturalistic clinical environment is effective in significantly reducing the number of readmission days in a group of patients suffering from long-term and persistent severe mental illness.

Comparing patterns and costs of schizophrenia care in five European countries: the EPSILON study. European Psychiatric Services: Inputs Linked to Outcome Domains and Needs

OBJECTIVE

To compare service utilization and cost profiles of people with schizophrenia living in Europe in order to understand differences in treatment and care costs.

METHOD

Cross-sectional samples were taken of people with schizophrenia in five European locations. Sociodemographic, clinical and service use data were collected via interviewer-administered questionnaires. Site-specific unit costs were obtained, transformed subsequently into a single currency (UK pound). Multiple regression analyses were conducted.

RESULTS

There were widespread and considerable differences between sites in service utilization patterns and associated costs. Higher needs, greater symptom severity and longer psychiatric history are associated with higher costs: quality of life and service satisfaction are not. Few differences were found between sites in patterns of association with cost.

CONCLUSION

Comparative analyses of the use and cost of mental health services can highlight existing variations helpfully in service provision and uptake. Methodological consistency is required if meaningful conclusions are to be drawn from such comparative data.

The Maudsley long-term follow-up of child and adolescent depression: 3. Impact of comorbid conduct disorder on service use and costs in adulthood

BACKGROUND

Depression in childhood or adolescence often has morbidity implications continuing into adulthood, generating needs for specialist services and support.

AIMS

To estimate the patterns of service use and costs in adulthood of former patients.

METHOD

Service use and other cost-related data were collected from former patients. Comparisons were made between those people with and without comorbid conduct disorder in childhood and with data for the general population.

RESULTS

Data on 91 people with depression (only) and 49 with comorbid conduct disorder revealed high adulthood service utilisation rates and costs. Inpatient care and criminal justice services were used more frequently by the comorbid group and total costs were significantly higher. There were also indications of higher service use by the comorbid group than the general adult population.

CONCLUSIONS

The high and enduring long-term costs associated with childhood depression and conduct disorder give further reason for early and effective intervention.

Does case management work? The evidence and the abuse of evidence-based medicine

OBJECTIVES

This study reviews typologies of psychiatric case management and then discusses the efficacy, effectiveness and cost effectiveness of psychiatric case management, with particular focus on evidence from Australia and the UK. Subsequently, it aims to examine the way such evidence has been interpreted in the context of UK psychiatric research and services. Finally it examines the ways in which, by the selective reviewing or editorializing of evidence, case management has been brought into disrepute in the UK.

METHOD

This study reviews literature of the recent evidence for case management, and asks three questions of case management: has it been shown to be efficacious in controlled research, is it effective in applied settings, and is it cost effective? An examination is then made of the concurrent representations of the UK evidence in both the academic literature and the media.

RESULTS

There is strong evidence for the efficacy effectiveness and cost-effectiveness of case management in psychiatry, the closer it conforms to active and assertive community treatment models. It appears, however, that studies and evidence-based reviews of case management have possibly been misused and misrepresented in a highly charged atmosphere of professional media debate. The potential for this abuse is not limited to psychiatry and remains a challenge for all evidence-based practice.

CONCLUSION

On the evidence, assertive community treatment case management is one of the most effective interventions in psychiatry today. Despite improving the evidence base for practice (e.g. as has occurred for case-management in psychiatry), evidence-based medicine (EBM) is still susceptible to compromise and misrepresentation, due to unexamined or undeclared bias. Unless this potential for abuse is recognized and checked, EBM in psychiatry is in danger of being discredited at the hand of some of its own proponents. There is a need for more rigorous pursuit of evidence-based psychiatry, including more systematic declaration of bias in all research, whether quantitative or qualitative in design.

Avaliação das limitações no comportamento social em pacientes psiquiátricos de longa permanência

Este texto trata de uma avaliação do comportamento social de pacientes psiquiátricos de longa permanência. Estudos recentes concentram-se nesse tema, considerando-o relevante na transferência do eixo da atenção do hospital para a comunidade. Para avaliar dificuldades e limitações de uma população com longo período de institucionalização, utiliza-se a Social Behavioural Schedule (SBS), que cobre áreas do comportamento referentes às principais dificuldades de pacientes crônicos. Selecionou-se uma amostra de 46 pacientes de uma população de 200 mulheres, com longa história de internação psiquiátrica, residentes em duas moradias protegidas e quatro pavilhões do Núcleo Franco da Rocha (NFR), do Instituto Municipal Juliano Moreira, no Rio de Janeiro. Os resultados obtidos foram comparados aos dados de uma amostra de moradores em um albergue de sem tetos e aos de pacientes de um hospital psiquiátrico, ambos situados em Londres. Os resultados sugerem que significativo percentual dos pacientes que vivem longo tempo em hospitais teriam condições de viver em residências na comunidade.

Establishing the efficacy and cost effectiveness of community intensive case management of long-term mentally ill: a matched control group study

OBJECTIVE

The study attempted to identify whether chronic mentally ill persons after receiving intensive case management (ICM) could demonstrate improved inpatient service utilisation compared with a matched control group cohort. Costings were measured to observe whether the increase in providing intensive outpatient contacts would be offset by savings in reduced inpatient service utilisation.

METHOD

Eighty ICM patients were matched on ICD-9 diagnosis, age, gender, length of illness, age at first inpatient and outpatient contact, marital status, educational level, employment status, country of birth, year of arrival to Australia and religion. Inpatient bed-days and outpatient contacts were recorded and compared 12 months prior to ICM treatment, 12 and 24 months after ICM using within/between group repeated measures analysis of variance.

RESULTS

The ICM group demonstrate significant reductions in inpatient service utilisation both within the 12- and 24-month period after receiving ICM treatment. The cost differential by 24 months of treatment was $801,475 in favour of the ICM model. The increase in costs of outpatient contacts were offset by a significant reduction in inpatient service utilisation.

CONCLUSION

When outpatient contacts averaged one contact a week for the duration of the study period no significant reductions in inpatient service utilisation was recorded, as demonstrated by comparison with the matched control group. By increasing outpatient contacts by 3-4 contacts a week, inpatient contacts reduced by 36.8%. ICM is an efficacious and cost effective way to implement community-based services to the chronically long-term mentally ill.

Direct and indirect costs of schizophrenia in community psychiatric services in Italy. The GISIES study. Interdisciplinary Study Group on the Economic Impact of Schizophrenia

BACKGROUND

The present work is a cost-of-illness (COI) study that aims at assessing total direct and indirect costs of schizophrenic patients in community psychiatric services in Italy and identifying the variables that influence costs.

METHODS

A retrospective prevalence-based multi-centre COI study, was designed. Ten community mental health centres (CMHC) were involved and 100 patients were recruited. Data on patients' costs were gathered through specifically designed instruments.

RESULTS

More than half total direct costs were attributed to CMHC interventions. The yearly average costs of schizophrenia per patient amounted to nearly ITL 50 million: 30% for direct costs and 70% for indirect costs.

CONCLUSION

CMHCs tend to manage long-term ill patients by adopting a strong community-based system of care. Schizophrenia is correlated to loss of working days and lack of well-being. From the results of this study, it might be argued that the de-institutionalisation programme has produced 'spillovers' in terms of families' greater involvement in patients management.

Ethics of community psychiatry

Psychiatric care in the community gives rise to ethical dilemmas which resemble those associated with predominantly institutional care. However, there are also dilemmas specifically associated with community care, many of which are conceptual as well as practical. Papers addressing both conceptual and practical ethical dilemmas are reviewed including some papers which deal with the ethical issues associated with violence in the community by the mentally ill.

User perspective on needs and satisfaction with mental health services. PRiSM Psychosis Study. 8

BACKGROUND

Measurement of the impact of different types of service provision on the views of service users is important in planning mental health services.

METHOD

Needs (met and unmet) and satisfaction with services, were assessed. People with psychosis (n = 131) were interviewed before (Time 1) and after (Time 2) the introduction of two community mental health services in south London. One was intensive, with two specialist teams, the other standard. Outcomes were compared at Time 2, controlling for the Time 1 values.

RESULTS

Overall, 70% of needs were met and mean satisfaction was between 'mixed' and 'mainly satisfied'. There was evidence for higher met needs in the intensive sector, but no evidence for lower unmet needs in the intensive sector or for differences in satisfaction. The additional needs met by the intensive service were associated with aspects of basic living situation. Satisfaction was negatively correlated with both unmet and met needs.

CONCLUSIONS

Both services were reasonably successful, with little difference from the user perspective. The intensive service provided benefits in terms of met needs, but this has to be balanced against a possible increase in unmet needs.

From efficacy to effectiveness in community mental health services. PRiSM Psychosis Study. 10

BACKGROUND

The PRiSM Psychosis Study investigated the outcomes of community mental health services for epidemiologically representative cases of psychosis in London.

METHOD

The results presented in the preceding nine papers are interpreted.

RESULTS

(a) The health and social gains reported in experimental studies of community health services are replicable in ordinary clinical settings, and are more effective than hospital-oriented services which they replace. (b) Dilution does occur--these gains are less pronounced than in experimental (efficacy) studies. (c) Both models of community services produced a range of improved outcomes. (d) Some limited extra advantages (in terms of met needs, improved quality of life, and social networks) were found in the intensive sector. (e) There is no consistent evidence that community-oriented services (which include in-patient beds) fail service users, their families or the wider public. On balance the results weigh slightly in favour of the two-team model (for acute and continuing care) in terms of clinical effectiveness, but the general model is almost as effective and is less expensive.

CONCLUSIONS

The evidence supports a community-oriented rather than a hospital-oriented approach and there is little difference between the community mental health team models.

Rationale and design. PRiSM Psychosis Study I

BACKGROUND

This paper sets out the rationale for the PRiSM Psychosis Study, and the research design used. Nine accompanying papers present the main results. The questions addressed by the PRiSM Psychosis Study are: can the gains of experimental studies which have demonstrated benefits arising from treatment by community mental health teams be translated to routine settings? If so, are the benefits diluted in ordinary clinical practice? What are the costs?

METHOD

A prospective nonrandomised controlled trial of two types of community mental health service, in two phases: case identification followed by patient interviews. For the case identification the research team conducted the complete ascertainment of all prevalent cases of psychosis in the two study catchment areas in the index year (1991-1992). From all 514 patients with psychotic disorders thus identified, 302 were randomly allocated for interview, along with a key informant clinician and a carer. Interviews were under taken at two time points, two years apart.

RESULTS

This paper presents the socio-demographic, clinical and ethnic characteristics of the patients.

CONCLUSIONS

The people with psychosis interviewed for the PRiSM Psychosis Study are representative of the whole epidemiologically based patient population identified.